Basic Information
Provider Information | |||||||||
NPI: | 1922625102 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GEORGE | ||||||||
FirstName: | FIJI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3441 DONEGAL WAY | ||||||||
Address2: |   | ||||||||
City: | SNELLVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300398635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6787795790 | ||||||||
FaxNumber: | 6783799209 | ||||||||
Practice Location | |||||||||
Address1: | 1700 MEDICAL WAY | ||||||||
Address2: |   | ||||||||
City: | SNELLVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300782195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709790200 | ||||||||
FaxNumber: | 6786281240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2020 | ||||||||
LastUpdateDate: | 07/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RPH021581 | GA | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.